Why haven't we cured tinnitus?

Towards the end of last year I attended the British Tinnitus Associations Annual Conference held at the impressive Goldsmiths University in London.

It was buzzing with professionals sharing experiences, a review of the latest research and future partnerships between the British Tinnitus Association and clinical researchers. There were discussions around tinnitus and sleep, a fascinating talk on the genetic nature/nurture considerations of tinnitus along with some case studies and some live consultations. Whilst reading through the conference programme one presentation in particular caught my eye. And the reason it did is because it is a question that I get asked a lot - 'Why haven't we cured tinnitus?'

There is lots to talk about in answer to this question and I wanted to share some the reasons with you.

A good place to start is finding out what treatment patients want. This might seem like an obvious question but what does a cure for tinnitus look like?

You may have you own ideas about what treatment type you would prefer. Some research in 2012 conducted by the Australian Tinnitus Society tried to answer this very question. The choices given to them included external devices such as a pillow speaker and hearing aids/sound generators, a pill, an implanted device such as a cochlear implant or other brain surface implanted devices. Interestingly, the most commonly desired treatment for tinnitus was an effective drug. 52% of those who took part in the study would be very likely to try medication if it offered tinnitus loudness and annoyance reduction of a half, rising to 62% if it offered the chance of complete elimination of the tinnitus. In addition, those who were assured a reduction of tinnitus by half or a complete elimination would be prepared to pay between A$1000 - A$5000.

If this is the case, then why are drug companies not developing such a medication. It sounds like it could be lucrative?

The question a drug company will ask themselves, quite crudely you might think, is: Would a cure for tinnitus be financially beneficial?". Action on Hearing Loss (formerly RNID) in 2005 suggested that a tinnitus drug could have a product value of $689 million in its first year of launch (Vio & Holme 2005), equivalent to just over $1 billion today. This study also estimated that at that time, there were 13 million people in Western Europe and the United States actively seeking help for their tinnitus and that 4 million off-label prescriptions were written each year. Seems surprising that they haven't developed something already doesn't it? However, on the flip side, it is incredibly expensive to bring a new drug to market. Paul et al in 2010 estimated this cost to be US$1.8 billion. This is the current cost of each new molecular entity (NME). In addition, drug patents last 20 years. The average time of discovery of a drug to marketing is 12 years. This only gives drug companies 8 years of protected sales.

So what can we can deduce from all of this? Tinnitus has no current treatment yet the financial cost of tinnitus is high at both a healthcare and societal level. Patients are currently dissatisfied with the treatment options that are available to them and would prefer a pharmacological answer.

So what is stopping things progressing? Well, one of the main stumbling blocks is that we have no objective way of determining whether someone has tinnitus, how severe the tinnitus is and whether treatments improve tinnitus. In addition, some studies dating back to 1984 show that the placebo effect can have as much of a positive effect on tinnitus as some drug treatments used in clinical trials.

Let's also bear in mind that most patients are told at primary healthcare levels that there is no cure for tinnitus so it is also difficult to know how many people are actually "suffering" with tinnitus as they never progress in the system. We cannot forget those who never seek a primary care opinion in the first place for this same reason. Given there is no objective way of determining the severity of tinnitus and no objective way of measuring whether treatments improve tinnitus, how do we assess the impact of an intervention. In healthcare, there are a number of biomarkers for different health conditions, ie cholestrol is a well known biomarker of risk for coronary heart disease. We don't have a biomarker for tinnitus. We may be waiting patiently for a cure, there are many reasons to explain why this is taking as long as it is.

So, what are the current treatments for tinnitus? Well these range from hearing aids to cochlear implants, sound therapy, mindfulness and relaxation training therapy have their place too. A little more invasive but with degrees of success has been botox and surgery (deconstruction and decompression). However, the primary reason for consenting for such interventions is not always tinnitus.

Looking ahead, what can we expect in the absence of a pharmacological solution? Well, there is plenty of research ongoing which should reassure you that as a tinnitus sufferer, you are not forgotten. A recent paper published in the 'Journal of Psychology Research and Behaviour Management' showed very positive results. The study looked at the success of cognitive behavioural therapy (CBT) in alleviating the distress of tinnitus. The results showed that whilst CBT didn't reduce the loudness of the tinnitus, 65% of patients in the study reported a 5/5 score for effectively reducing the distress the tinnitus caused. Furthermore, CBT was just as successful when delivered in group settings as it was in 1-1 settings and was also effective when delivered via the internet with the support of an audiologist. I was really impressed with these results.

Another study published in 'American Journal of Audiology' looked at the level of the stress hormone cortisol in patients saliva on waking each morning. The purpose of the study was to see if these levels might be an effective measure of tinnitus distress. Waking up is the time of day when you are secreting the highest levels of cortisol in anticipation of the day ahead. It is understood already that too much cortisol in the morning is a sign of stress and too little is a sign of burnout. Having high levels in the morning has been linked to disorders such as anorexia and obsessive compulsive disorder. Low levels are more linked to depression and chronic fatigue. Research suggests patients with distressing tinnitus have little cortisol upon wakening. This means they have no control, an inability to relax and emotional distress caused by the tinnitus so their bodies have shut down cortisol production. So whilst the study aim was to look at measuring tinnitus distress, it also reminds is that anything you can do to reduce your levels of stress will assist in resetting your cortisol levels so that the production is within normal limits.

Whilst there is no cure, there are many things you can do to help reduce your perception and indeed your distress of tinnitus. I think a pharmacological solution is not going to present itself anytime soon but it should be reassuring to know that research is still ongoing and different interventions, some conservative and some invasive are producing some very positive results. Treat your tinnitus as holistically as possible. Look at anything you can do that triggers a sense of happiness and well-being. Look into CBT or sound relaxation. Mindfulness or hypnotherapy. There is no one solution, and what may work for one, may not work for another. Above all, do not look for a cure. There isn't one. Look to improve your overall life and in the process you may find improvements to be had on your tinnitus.

Should you like an appointment to talk about your tinnitus, please do get in touch with me. At this current time, I am able to offer telephone appointments or Zoom appointments.